Effectiveness of Conservative Treatment without Early Colonoscopy in Patients with Colonic Diverticular Hemorrhage

Abstract

Aim. This study was aimed to clarify the effectiveness of conservative treatment without performing early colonoscopy and the indications for early colonoscopy in patients with colonic diverticular hemorrhage. Methods. This retrospective study included 142 participants who were urgently hospitalized due to bloody stools and were diagnosed with colonic diverticular hemorrhage between April 2012 and December 2016. At the time of hospital visit, only when both shock based on vital signs and intestinal extravasation on abdominal contrast-enhanced computed tomography were observed, early colonoscopy was performed within 24 hours after hospitalization. However, in other cases, patients were conservatively treated without undergoing early colonoscopy. In cases of initial treatment failure in patients with shock, interventional radiology (IVR) was performed without undergoing early colonoscopy. Results. Conservative treatment was performed in 137 (96.5%) patients, and spontaneous hemostasis was achieved in all patients. By contrast, urgent hemostasis was performed in five (3.5%) patients; three and two attained successful hemostasis via early colonoscopy and IVR, respectively. There were no significant differences between two groups in terms of early rebleeding (7.3% vs. 0%,P=0.690) and recurrent bleeding (22.7% vs. 20.0%, P=0.685). The factors associated with the cumulative recurrent bleeding rates were a previous history of colonic diverticular hemorrhage (hazard ratio 5.63, 95% confidence interval 2.68–12.0, P<0.0001) and oral administration of thienopyridine derivative (hazard ratio 3.05, 95% confidence interval 1.23–7.53, P=0.016). Conclusions. In this series, conservative treatment without early colonoscopy was successful in patients with colonic diverticular hemorrhage.

Risk factors of interventional radiology/surgery for colonic diverticular bleeding

“…According to Doi et al who studied 142 patients with CDB, in cases of both shock and positive CT extravasation, two of five patients developed severe bleeding who required hemostasis with IR. 24 In a report by Nakatsu et al who studied 346 patients with CDB, the rate of bleeding source identification in emergency colonoscopy was 68% for positive extravasation and 20% for negative extravasation, and it was significantly higher for those with positive extravasation. 25 Shock and positive extravasation strongly indicate massive or active bleeding, and rapid hemostatic treatment is necessary while maintaining the vital signs in an emergency situation.…”

“… 23 Both are findings that indicate active bleeding for CDB. According to Doi et al who studied 142 patients with CDB, in cases of both shock and positive CT extravasation, two of five patients developed severe bleeding who required hemostasis with IR 24 . In a report by Nakatsu et al who studied 346 patients with CDB, the rate of bleeding source identification in emergency colonoscopy was 68% for positive extravasation and 20% for negative extravasation, and it was significantly higher for those with positive extravasation 25 .…”

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

“…Further real-world data on conservative management of patients hospitalized with LGIB is needed given the high number of colonoscopies performed and the correspondingly low rate of endoscopic intervention. In a single-center, retrospective report of 142 consecutive patients with LGIB, conservative management, based on an elective colonoscopy within 2 weeks after spontaneous hemostasis in patients who had an initial negative CTA and did not present with shock, was an effective management strategy (141). In a retrospective cohort of 97 patients with stable LGIB, 38% of the cohort was discharged early from the ED with outpatient management; factors associated with early discharge included younger age, lack of antithrombotic medications, higher index hemoglobin and albumin, and lower BUN and creatinine scores.…”

Risk factors for difficult endoscopic hemostasis for colonic diverticular bleeding and efficacy and safety of transcatheter arterial embolization

“…[37] Recent reports regarding early colonoscopy for diverticular hemorrhage recommend conservative treatment except in severe cases, as the identification rate of SRH was 15% to 42% and the early and late rebleeding rates were not significantly different compared to patients who were treated conservatively. [36][37][38][39] In contrast, the identification rate of the bleeding source by angiography is estimated to be 25% to 75%. [13,40,41] In the current study, the identification rate of the bleeding source by angiography was 66.7%, which was considered effective for patients with repeated rebleeding in whom the bleeding source was not identified via colonoscopy.…”

“…[36] Doi et al reported that 96.5% of patients with diverticular bleeding were successfully treated conservatively without early colonoscopy. [37] Recent reports regarding early colonoscopy for diverticular hemorrhage recommend conservative treatment except in severe cases, as the identification rate of SRH was 15% to 42% and the early and late rebleeding rates were not significantly different compared to patients who were treated conservatively. [36–39]…”